Understanding Cleft Lip and Cleft Palate in Children
A cleft lip or cleft palate diagnosis can feel overwhelming for parents, especially when it comes during pregnancy or shortly after birth.
These are among the most common birth defects affecting children, and while they do require specialized care, the outcomes with proper treatment are excellent.
At Michigan Pediatric ENT Associates (MPENTA), we want families to feel informed and supported from the moment of diagnosis through every stage of their child’s care.
What is a Cleft Lip?
A cleft lip is a notch or gap in the tissue that forms the lip.
Beneath the nose and above the lip are faint lines or a bulge of tissue running from below the nostril to the top of the lip. These lines are called philtrum lines and this is where clefts can develop.
The majority of cleft lips (about 80%) are unilateral, meaning they are located on only one of the philtrum lines. Left philtrum cleft lips are the most common. The remaining 20% of cleft lips occur bilaterally, or on both philtrum lines.
By definition, the cleft or gap can range in size from just a small portion of the upper lip or the vermilion border to spanning the entire lip up to the nose.
Cleft Lip Symptoms and How to Identify One
A cleft lip is often identified before birth during a routine ultrasound, typically around 18 to 21 weeks of pregnancy.
However, not all cases are detected prenatally, and many are identified at birth during the initial newborn examination.
The physical opening in the lip is usually immediately visible. In cases where a cleft palate is also present without an accompanying cleft lip, diagnosis can sometimes be delayed as it is not always visible from the outside and requires a direct examination of the inside of the mouth.
The most common symptom of a cleft lip is the visible appearance of a physical opening or split in the upper lip. The gap may appear on one side of the lip as a small notch, or it can extend up to the nose.
More significant cleft lips can affect both sides of the lip. Beyond the visible physical appearance, a cleft lip can also contribute to difficulties with feeding, speech development, and dental health as the child grows.
Common Causes of Cleft Lip
Cleft lip is one of the most common birth defects in the world. In the United States, approximately 1 in every 1,050 babies is born with a cleft lip, with or without a cleft palate.
It occurs more frequently in boys than in girls and is more common in children of Asian, Latino, and Native American descent. Despite how common it is, many parents have never encountered it before their own child’s diagnosis.
In most cases, there is no single identifiable cause of cleft lip. It is generally understood to result from a combination of genetic and environmental factors during early fetal development. A family history of cleft lip or palate increases the likelihood of the condition occurring.
Other contributing factors may include certain medications taken during pregnancy, nutritional deficiencies such as low folic acid intake, exposure to tobacco smoke or alcohol during pregnancy, and certain viral infections during the first trimester.
How to Safely Treat Cleft Lip
For an isolated cleft lip, where the cleft occurs alone without a cleft palate or any other abnormality, the cleft is repaired surgically. This repair is usually performed between 2 and 10 weeks of age, depending on the size and health of the infant.
The goal of this surgery is primarily to close the cleft, so the infant can suck normally. A second surgery, if needed, is performed as the child ages to correct any cosmetic facial or other abnormalities. A plastic and reconstructive surgeon usually performs this surgery.
What is a Cleft Palate?
A child born with a cleft palate defect will have a deformity on the roof of the mouth behind the two front teeth.
The roof palate spans from the roof of the mouth behind your two upper teeth to the small bag of tissue dangling at the back, called the uvula.
The palate consists of the hard palate at the front, transitioning to the soft palate or velopharynx, and ending at the uvula.
A cleft palate is an abnormal opening in the palate, resulting from the failure of the roof of the mouth to close during the development of the fetus in the first four to eight weeks of pregnancy.
This opening can range in length from a split in the uvula, called a bifid uvula, to a cleft or gap through the soft and hard palates.
Most cleft palate deformities expose the underside of the nose, but it can also be hidden if the lining is smooth and unbroken, called a submucous cleft.
Cleft Palate Symptoms and How to Identify One
A cleft palate can often be detected before the baby is born through an ultrasound. Most clefts are easily picked up during the initial exam of the newborn. Occasionally, very small clefts may not be identified until some related conditions are observed, such as ear problems or regurgitation of liquids into the nose.
A cleft palate can be harder to identify than a cleft lip because it is not always visible from the outside. The symptoms, however, can be wide-ranging and affect several aspects of a child’s development and daily functioning.
The most common and often earliest sign is difficulty feeding. Infants with a cleft palate are frequently unable to create the suction needed for breastfeeding or bottle feeding, causing them to swallow air, feed slowly, or experience milk coming out through the nose during feeding.
As the child grows, other symptoms may become more apparent, including:
- Nasal-sounding speech or difficulty pronouncing certain sounds, which occurs because air escapes through the opening in the palate rather than being directed through the mouth properly.
- Recurrent ear infections and hearing loss, which are very common in children with cleft palate due to dysfunction of the Eustachian tubes that drain the middle ear.
- Dental problems including missing, extra, or misaligned teeth, particularly in the area of the cleft.
- Chronic nasal congestion or difficulty breathing through the nose.
- Difficulty swallowing or a tendency for food and liquids to travel into the nasal cavity.
- In some children, a cleft palate is part of a broader syndrome involving other developmental differences, in which case additional symptoms may be present depending on the specific diagnosis.
- Because several of these symptoms, particularly ear infections, hearing loss, and nasal issues, fall within the scope of pediatric ENT care, early involvement of a specialist is important.
Common Causes of Cleft Palate
The incidence of cleft lip and/or cleft palate is 1 in 750 live births. This incidence is slightly affected by the race and/or sex of the child. An isolated cleft palate (occurring without a cleft lip) appears in about a quarter of these, with an increased incidence in females. The remainder either involves an isolated cleft lip (25%) or both cleft lips and palates (50%).
Most of the time, the cause of a cleft palate is a combination of many factors.
Some of the conditions that may result in a cleft lip and/or palate are:
Environmental Factors
It is important to remember that a cleft lip and palate occur by 8 weeks of pregnancy, usually before most women know they are pregnant. That said, factors that may increase the likelihood of clefting include substances the mother ingested or was exposed to early on in the pregnancy.
The position of the fetus or amniotic bands (strings of tissue in the uterus) may also contribute to clefting.
Genetic or Inherited Clefts
Families where parents or other relatives have a cleft lip and/or palate may have an increased likelihood of producing children with clefting.
It is recommended that the parents of any child born with a cleft undergo genetic testing so that they can make informed decisions about future children.
To give a brief overview, if relatives and both parents of a child are normal, but the child is born with an isolated cleft palate, the chance of the next baby having a cleft palate is 2%. If one of the family’s relatives is affected, the chance increases to 7%. If your baby has a cleft palate along with other congenital problems, the chance that the next baby will have a cleft palate drops again to 2%.
Cleft Syndrome
A syndrome is an abnormality in inherited material (genes on chromosomes) that result in malformations or deformities that form a recognizable pattern. Most clefts are not part of a syndrome. But if a child is born with a cleft, it is important to evaluate them to ensure they do not have other deformities that would be part of a syndrome.
How is a Cleft Palate Treated Safely?
Treatment for cleft palate will depend on each child’s needs and specific situation. There are two aspects of cleft palate treatment, including repairing the cleft itself and treating the common conditions of cleft palate.
In treating the cleft itself, there are stages of surgical cleft palate repair or palatoplasty. These stages occur between the ages of 6 months and 1 year.
Many ENT specialists will also treat the common conditions associated with cleft palate, including:
Breathing Problems
With a cleft palate, the tongue has a tendency to fall back into the mouth and block the airway. In some children, the jaw bone (mandible) is also small which makes breathing even more difficult. This is treated by helping to keep the airway open with positioning of the child or insertion of various devices designed to help breathing.
Feeding Problems
In an infant with cleft palate, feeding may be difficult because the food does not follow the normal swallowing pathway into the back of the throat and, therefore, can confuse the child.
There may also be some difficulty in using a bottle or breast-feeding. The abnormal roof of the mouth does not allow normal pressure or suction to be applied to the nipple, which results in inadequate sucking. Treatment consists of using specially formed bottles and nipples that help aid in the feeding of children with clefts. Trial and error with different methods and patience are also important.
An occupational therapist may be of help if feeding continues to be a problem.
Increased Incidence of Ear Infections (Otitis Media)
Fluid in the middle ear (effusion) and repeated ear infections are present in at least 50% of children with a cleft palate. This is a result of the abnormal insertion of the muscles to the tube that drains the middle ear (Eustachian tube), which results in problems opening up the tube to equalize pressure and to help drain any fluid if present.
Even after cleft palate repair, close follow-up of the patient’s ears will be necessary into adolescence due to the high likelihood of continued middle ear problems. Please see otitis media and tympanostomy tube placement for more information on this condition.
Hearing Loss
This is related to the frequency of ear infections. However, with proper treatment of the ear infections, and periodic hearing evaluations, the incidence of hearing loss should be significantly reduced.
Speech Problems
A patient with a cleft palate also has abnormal insertion of muscles into the back of the throat. As these muscles are involved with the production of normal speech, speech problems can result.
Treatment of speech difficulties is handled both surgically and with speech therapy, using a team approach. As ear nose and throat specialists, we have extensive training in the reconstruction of muscles that are involved with speech.
Because we also work closely with speech therapists, we can utilize the team approach to ensure appropriate development of speech and, if necessary, use specialized diagnostic tools to evaluate and treat any speech problems.
Dental Problems
Many times children with clefts have teeth in unusual positions or need temporary prosthetic devices to aid with feeding, speech, etc. while the palate is undergoing reconstruction. This long-term treatment consists of a referral to a pediatric dentist, and/or an orthodontist, who helps to achieve a normal dental arch and teeth positioning, and a prosthodontist to help with specific dental appliances.
Other Issues
These can include specific needs of the patient or the entire family regarding emotional issues, financial hardships, or other concerns.
There are a variety of other professionals available to help provide the best possible care for the patient, as well as the family as a whole. It is always our goal to provide your child with the best care possible so if you have any questions or concerns during the evaluation or treatment of your child, do not hesitate to bring them to our attention.
Trust MPENTA to Safely Treat Your Child’s Cleft Lip or Cleft Palate
At MPENTA, our team works closely with families affected by cleft lip and cleft palate to ensure every child receives the comprehensive, coordinated care they need.
While surgical repair of the lip and palate is typically performed by a craniofacial or plastic surgeon, the ENT-related complications that often accompany these conditions, including ear infections, hearing loss, speech difficulties, and nasal obstruction, fall squarely within our area of expertise.
We are proud to be part of the multidisciplinary care team that supports these children from infancy through adolescence. If your child has been diagnosed with a cleft lip or palate, reach out to us to learn how we can help.
This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions. This article was reviewed by ENT specialists.
